Provider Demographics
NPI:1184001208
Name:BROCK, MELISSA RENEE (DOM)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:RENEE
Last Name:BROCK
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 MIGUEL CHAVEZ RD
Mailing Address - Street 2:UNIT 1613
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505
Mailing Address - Country:US
Mailing Address - Phone:503-891-4862
Mailing Address - Fax:
Practice Address - Street 1:1642 ST MICHAEL'S DRIVE
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-670-6891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-27
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDOM1277171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist